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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002637
Report Date: 12/01/2022
Date Signed: 12/01/2022 10:32:24 AM

Document Has Been Signed on 12/01/2022 10:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:EDENIC HAVEN 2FACILITY NUMBER:
515002637
ADMINISTRATOR:MUPUNDU, ELLIASFACILITY TYPE:
735
ADDRESS:2007 FALLS DRTELEPHONE:
(530) 713-7594
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 4CENSUS: 4DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ellias MupunduTIME COMPLETED:
10:40 AM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing one. Administrator arrived shortly after LPA arrived and completed the visit. Caregiver screened LPA upon entering the facility.

This main entrance opens to the first of two sitting areas. To the right of the main entrance is a very short hallway that leads to two private resident rooms. The larger of the two rooms has a full private bathroom and a sliding glass door leading to the backyard. To the left of the main entrance is a nook that is used as an office space. To the left of the first sitting area is a hallway leading to two private resident rooms, a full common bathroom, and a laundry room. To the left and rear of the main entrance is the kitchen and the second sitting area that has a door leading to the backyard. The backyard has a locked shed. There are locked cabinets for medications and confidential files.

LPA reviewed three of four resident files and two staff files.

A couple of topics were discussed with the Caregiver and Administrator.

The following shall be updated and submitted to licensing within 30 days;
LIC 500- facility personnel or staff schedule
LIC 308- designation of administrative responsibility
LIC 610- emergency disaster plan


No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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